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Xiaomin Liu, Desheng Xu, Yipei Zhang, Dong Liu and Guoxiang Song

Object

This study was undertaken to evaluate clinical outcomes and tumor control in patients harboring orbital cavernous hemangiomas (OCHs) that had been diagnosed based on findings of imaging studies and treated by Gamma Knife surgery (GKS).

Methods

Between 1995 and 2008, 23 patients harboring OCHs that had been diagnosed on the basis of imaging findings were treated using GKS; complete follow-up data are available in all cases. The median treatment volume was 1.5 cm3 (range 0.15–10.10 cm3), the median tumor margin dose was 15 Gy (range 12–20 Gy), and the median follow-up period was 12 months (range 6–120 months).

Results

A decrease in tumor size was found in 20 patients, and no tumor progression was observed after GKS. Eleven of 14 patients whose visual function had been adversely affected prior to treatment had improved visual acuity at the last assessment. Side effects of the procedure included orbital pain in 3 patients and chemosis in 2 patients.

Conclusions

In this preliminary experience, GKS proved to be an effective treatment for OCHs diagnosed on the basis of imaging findings. Additional follow-up is necessary, and the long-term side effects of the procedure still need to be determined.

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Dong Liu, Desheng Xu, Zhiyuan Zhang, Yipei Zhang and Ligao Zheng

Object

The authors sought to assess the results of Gamma Knife surgery (GKS) in patients with vestibular schwannomas (VSs).

Methods

Seventy-four consecutive patients (33 men and 41 women) were evaluated by means of serial imaging studies, clinical examinations, and questionnaires. Nineteen patients had undergone resection of their VS. Facial nerve function was normal in 63 patients (85.1%) before GKS, and 63.5% of them had useful hearing. The prescription peripheral dose varied between 10 and 14 Gy (mean 12.27 ± 0.96 Gy); the corresponding central dose was 21 to 30 Gy (mean 24.9 ± 2.18 Gy). The mean volume of the tumor at GKS was 10.79 ± 5.52 ml (range 0.11–27.8 ml). A mean of eight isocenters (range 3–17) was used for treating these lesions.

At a median follow-up period of 68.3 months (range 30–122 months), tumor shrinkage was observed in 60 patients (81.1%), and the tumor size was stable in 11 (14.8%). Persistent neuroimaging demonstrated evidence of progression in only three patients (4.1%): two underwent repeated GKS after an interval of 18 months and one continues to be observed. Five patients experienced trigeminal dysfunction: in three the dysfunction was transient and in the other two the dysfunction persists. Three patients suffered facial palsy. Useful hearing was preserved in 34 patients. Thirteen patients experienced some degree of hearing improvement. Deterioration of hearing was found in 13 of 62 patients who had Class I or II hearing before treatment.

Conclusions

Gamma Knife surgery prevents tumor growth; it achieves excellent neurological function preservation and produces few treatment-related complications.

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Wen-Dong Xu, Yu-Dong Gu, Jing-Bo Liu, Cong Yu, Cheng-Gang Zhang and Jian-Guang Xu

Object

The status of pulmonary function following phrenic nerve transfer surgery is still largely unknown because of the high degree of variability in the accessory phrenic nerve that may be involved. In the present study, pulmonary functions were assessed in patients before and after full-length phrenic nerve transfer surgery, in whom the phrenic nerve was severed at a location just before its entry into the diaphragm.

Methods

Fifteen patients (average age 27.4 years) with complete brachial plexus palsy underwent full-length phrenic nerve transfer. The phrenic nerve was harvested from the thoracic cavity by means of video-assisted thoracic surgery and then transferred to the musculocutaneous nerve. Postoperative pulmonary functions were retrospectively analyzed. Patients underwent follow-up evaluation for 42 to 48 months; four patients were eventually lost to follow up.

Although no patient experienced pulmonary problems following the surgery, all sustained varying degrees of diaphragmatic paralysis and elevation (for 1–1.5 intercostal spaces) on the surgically treated side as seen on chest x-ray films. Pulmonary functional parameters, including vital capacity, vital capacity in percentage of predicted values, residual volume, total lung capacity, forced vital capacity, and forced expiratory volume in 1 second, recovered to preoperative levels by 1 year postsurgery. In contrast, the postoperative maximal inspiratory pressure value was significantly decreased compared with the predicted values (average decrease ∼20%) in all of the patients, even at 4 years after the surgery.

Conclusions

In young patients with healthy lung function, unilateral phrenic nerve transection surgery can cause unilateral diaphragmatic paralysis and reduce the inspiration muscle force; however, most pulmonary function parameters gradually recover to preoperative levels within 1 year.

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Zihao Chen, Bin Liu, Jianwen Dong, Feng Feng, Ruiqiang Chen, Peigen Xie, Liangming Zhang and Limin Rong

OBJECTIVE

The purpose of this study was to compare the effectiveness and safety of anterior corpectomy and fusion (ACF) with laminoplasty for the treatment of patients diagnosed with cervical ossification of the posterior longitudinal ligament (OPLL).

METHODS

The authors searched electronic databases for relevant studies that compared the use of ACF with laminoplasty for the treatment of patients with OPLL. Data extraction and quality assessment were conducted, and statistical software was used for data analysis. The random effects model was used if there was heterogeneity between studies; otherwise, the fixed effects model was used.

RESULTS

A total of 10 nonrandomized controlled studies involving 819 patients were included. Postoperative Japanese Orthopaedic Association (JOA) score (p = 0.02, 95% CI 0.30–2.81) was better in the ACF group than in the laminoplasty group. The recovery rate was superior in the ACF group for patients with an occupying ratio of OPLL of ≥ 60% (p < 0.00001, 95% CI 21.27–34.44) and for patients with kyphotic alignment (p < 0.00001, 95% CI 16.49–27.17). Data analysis also showed that the ACF group was associated with a higher incidence of complications (p = 0.02, 95% CI 1.08–2.59) and reoperations (p = 0.002, 95% CI 1.83–14.79), longer operation time (p = 0.01, 95% CI 17.72 –160.75), and more blood loss (p = 0.0004, 95% CI 42.22–148.45).

CONCLUSIONS

For patients with an occupying ratio ≥ 60% or with kyphotic cervical alignment, ACF appears to be the preferable treatment method. Nevertheless, laminoplasty seems to be effective and safe enough for patients with an occupying ratio < 60% or with adequate cervical lordosis. However, it must be emphasized that a surgical strategy should be made based on the individual patient. Further randomized controlled trials comparing the use of ACF with laminoplasty for the treatment of OPLL should be performed to make a more convincing conclusion.

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Dong Liu, Yanhe Li, Yipei Zhang, Zhiyuan Zhang, Guoxiang Song and Desheng Xu

OBJECTIVE

This article is a preliminary evaluation of the efficacy of volume-staged Gamma Knife radiosurgery (GKRS) in the treatment of patients with orbital venous malformations (OVMs).

METHODS

Twenty patients with moderate to large OVMs were treated with volume-staged GKRS between March 2005 and October 2015. The series included 8 male and 12 female patients with an average age of 22.5 years (range 9–45 years). The diagnoses were confirmed intraoperatively and at pathological examination in 14 cases and presumed in accordance with clinical and imaging findings in 6 cases. The median OVM volume was 12.2 cm3 (range 7.1–34.6 cm3). The median interval between stages was 10 months (range 6–12 months). The tumor margin dose for each stage ranged from 11.0 to 13.5 Gy. The median duration of follow-up was 45.5 months (range 18–98 months).

RESULTS

Periodically scheduled MRI studies demonstrated evidence of a significant reduction of the original OVM volume in all cases. Visual acuity (VA) was preserved in 18 cases (90%). Five patients (25%) experienced vision improvement of varying degrees, and 13 (65%) experienced long-term preservation of VA at their pre-GKRS level. Deterioration in VA was observed in only 2 cases (10%). MRI demonstrated OVM regression after treatment in all cases, and all patients were found to have reduction of exophthalmos after volume-staged GKRS. Follow-up MRI revealed recurrence in only 1 case (5%). Three patients (15%) developed transient conjunctival edema.

CONCLUSIONS

This retrospective investigation indicates that volume-staged GKRS provides an effective management option in selected patients with OVMs, providing excellent visual outcomes. The study adds substantial support for volume-staged GKRS as a major treatment for OVMs.

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Fubing Liu, Zhenzhou Feng, Tianze Liu, Qinming Fei, Chun Jiang, Yuanchao Li, Xiaoxing Jiang and Jian Dong

OBJECT

This study sought to make a biomechanical comparison of 3 different posterior fixation techniques for 2-level lumbar spinal disorders.

METHODS

Eight fresh-frozen human cadaver lumbar spines (4 from L-1 to L-5, 4 from L-1 to S-1) were tested by applying pure moments of ± 8 Nm. Each specimen was first tested intact, and then the left facetectomies of L3–4 and L4–5 were performed to establish an unstable condition without removal of discs. Three instrumentation systems were then tested randomly: unilateral pedicle screw (UPS), UPS with contralateral translaminar facet screw (UPSFS), and bilateral pedicle screw (BPS). The range of motion (ROM) and the neutral zone (NZ) of L3–5 were measured.

RESULTS

All fixation types could reduce the ROM of L3–5 significantly in flexion, extension, and lateral bending, compared with the intact state. In axial torsion, only BPS reduced the ROM significantly, compared with the intact state. The UPSFS technique provided intermediate stability, which was superior to the UPS in flexion-extension and lateral bending, and inferior to the BPS in lateral bending. Compared with the intact state, the NZs decreased significantly for UPS, UPSFS, and BPS in flexion-extension, while not significantly in lateral bending and axial torsion.

CONCLUSIONS

In this study, among the 3 fixation techniques, BPS offered the highest stability, UPSFS provided intermediate stability, and UPS was the least stable for 2-level lumbar spinal disorders. UPSFS appeared to be able to offer a less invasive choice than BPS in well-selected patients with 2-level lumbar spinal disorders.

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Youlin Ge, Dong Liu, Zhiyuan Zhang, Yanhe Li, Yiguang Lin, Guokai Wang, Yongqing Zong and Enhu Liu

OBJECTIVE

The authors retrospectively analyzed the follow-up data in 130 patients with intracranial benign meningiomas after Gamma Knife radiosurgery (GKRS), evaluated the tumor progression-free survival (PFS) rate and neurological function preservation rate, and determined the predictors by univariate and multivariate survival analysis.

METHODS

This cohort of 130 patients with intracranial benign meningiomas underwent GKRS between May 2012 and May 2015 at the Second Hospital of Tianjin Medical University. The median age was 54.5 years (range 25–81 years), and women outnumbered men at a ratio of 4.65:1. All clinical and radiological data were obtained for analysis. No patient had undergone prior traditional radiotherapy or chemotherapy. The median tumor volume was 3.68 cm3 (range 0.23–45.78 cm3). A median margin dose of 12.0 Gy (range 10.0–16.0 Gy) was delivered to the tumor with a median isodose line of 50% (range 50%–60%).

RESULTS

During a median follow-up of 36.5 months (range 12–80 months), tumor volume regressed in 37 patients (28.5%), was unchanged in 86 patients (66.2%), and increased in 7 patients (5.4%). The actuarial tumor progression-free survival (PFS) rate was 98%, 94%, and 87% at 1, 3, and 5 years, respectively, after GKRS. Tumor recurred in 7 patients at a median follow-up of 32 months (range 12–56 months). Tumor volume ≥ 10 cm3 (p = 0.012, hazard ratio [HR] 8.25, 95% CI 1.60–42.65) and pre-GKRS Karnofsky Performance Scale score < 90 (p = 0.006, HR 9.31, 95% CI 1.88–46.22) were independent unfavorable predictors of PFS rate after GKRS. Of the 130 patients, 101 (77.7%) presented with one or more neurological symptoms or signs before GKRS. Neurological symptoms or signs improved in 40 (30.8%) patients, remained stable in 83 (63.8%), and deteriorated in 7 (5.4%) after GKRS. Two (1.5%) patients developed new cranial nerve (CN) deficit. Tumor volume ≥ 10 cm3 (p = 0.042, HR = 4.73, 95% CI 1.06–21.17) and pre-GKRS CN deficit (p = 0.045, HR = 4.35, 95% CI 0.84–22.48) were independent unfavorable predictors for improvement in neurological symptoms or signs. Six (4.6%) patients developed new or worsening peritumoral edema with a median follow-up of 4.5 months (range 2–7 months).

CONCLUSIONS

GKRS provided good local tumor control and high neurological function preservation in patients with intracranial benign meningiomas. Patients with tumor volume < 10 cm3, pre-GKRS Karnofsky Performance Scale score ≥ 90, and no pre-GKRS CN deficit (I–VIII) can benefit from stereotactic radiosurgery. It can be considered as the primary or adjuvant management of intracranial benign meningiomas.

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Xiaomin Liu, Qi Yu, Zhiyuan Zhang, Yipei Zhang, Yanhe Li, Dong Liu, Qiang Jia, Ligao Zheng and Desheng Xu

Object

The goal of this study was to evaluate the efficacy and safety of same-day stereotactic aspiration and Gamma knife surgery (GKS) for cystic intracranial tumors.

Methods

Between 1996 and 2007, 77 patients harboring cystic intracranial tumors underwent a same-day procedure of MRI-guided cyst aspiration followed by GKS. The diagnoses were metastatic tumor in 43 patients, glial tumor in 12 patients, vestibular schwannoma in 10 patients, craniopharyngioma in 9 patients, and hemangioblastoma in 3 patients.

Results

An improvement in symptoms was achieved in 68 patients (88.3%) immediately after cyst aspiration. The mean tumor volume in this group of patients was 25.1 cm3 before aspiration and 11.1 cm3 afterward. Hemorrhage during the course of aspiration was encountered in 1 patient. Transient nausea after cyst aspiration developed in 3 patients. There was no treatment-related hematoma, seizure, neurological deficit, or infection. The median follow-up period was 16 months (range 6–108 months). Tumor control was achieved in 50 (80.6%) of 62 patients who participated in follow-up for at least 6 months.

Conclusions

The same-day stereotactic aspiration and GKS procedure was safe in patients with cystic brain tumors. Prompt symptom relief was obtained after cyst aspiration. The decrease in tumor volume following aspiration made GKS more effective because a higher prescription dose could be administered with a lower possibility of radiation-induced side effects.

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Yanhe Li, Desheng Xu, Zhiyuan Zhang, Yipei Zhang, Dong Liu, Xiaomin Liu, Guokai Wang and Yiguang Lin

Object

The goal of this study was to assess neuroimaging and clinical outcomes in patients harboring brainstem metastases that were treated with the Leksell Gamma Knife.

Methods

Twenty-eight patients with brainstem metastases (32 lesions: 8 midbrain, 21 pontine, and 3 medullary) were consecutively treated with GKS. The primary cancer diagnoses in this group included 22 cases of lung cancer, 5 cases of breast cancer, and 1 case of rectal cancer. The median age of the patients was 61 years (range 45–83 years). The median treated lesion volume was 0.78 cm3 (range 0.03–5.6 cm3), and the median GKS margin dose was 16 Gy (range 12–20 Gy). Overall survival in these patients was calculated using the Kaplan-Meier method.

Results

The median survival time was 9 months after GKS (range 2–32 months). Survival was 39.3% at 1 year and 10.7% at 2 years. The tumor control rate in the series was 90.6% (29 of 32 lesions). Development of peritumoral edema occurred in 1 patient after GKS; 4 months after GKS, the edema disappeared.

Conclusions

Gamma Knife surgery using a median margin dose of 16 Gy is a safe and effective local therapy for patients with brainstem metastases.

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Xu-Yun Hua, Bin Liu, Yan-Qun Qiu, Wei-Jun Tang, Wen-Dong Xu, Han-Qiu Liu, Jian-Guang Xu and Yu-Dong Gu

Object

Contralateral C-7 nerve transfer was developed for the treatment of patients with brachial plexus avulsion injury (BPAI). In the surgical procedure the affected recipient nerve is connected to the ipsilateral motor cortex, and the dramatic peripheral alteration may trigger extensive cortical reorganization. However, little is known about the long-term results after such specific nerve transfers. The purpose of this study was to investigate the long-term cortical adaptive plasticity after BPAI and contralateral C-7 nerve transfer.

Methods

In this study, 9 healthy male volunteers and 5 male patients who suffered from right-sided BPAI and had undergone contralateral C-7-transfer more than 5 years earlier were included. Functional MRI studies were used for the investigation of long-term cerebral plasticity.

Results

The neuroimaging results suggested that the ongoing cortical remodeling process after contralateral C-7 nerve transfer could last for a long period; at least for 5 years. The motor control of the reinnervated limb may finally transfer from the ipsilateral to the contralateral hemisphere exclusively, instead of the bilateral neural network activation.

Conclusions

The authors believe that the cortical remodeling may last for a long period after peripheral rearrangement and that the successful cortical transfer is the foundation of the independent motor recovery.